Provider Demographics
NPI:1376636597
Name:LAKEPORT EMERGENCY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LAKEPORT EMERGENCY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-447-0296
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91077-1848
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6357
Practice Address - Country:US
Practice Address - Phone:626-447-0296
Practice Address - Fax:626-447-6057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64122207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095010Medicaid
CAZZZ29453ZMedicare PIN